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SAN JOAQUIN COUNTY 3ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT IFac il' ame: Inspection Date: AA I ) 1 -Iz - Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: anufacturer Training: �, -1 lr This UST facility is APPROVED to operate SERVICE Leak detector Spill bucket ❑ minimum 5 gallon ❑ ❑ mechanical Model: ❑ Caldwell System ❑ Other ❑ electronic Serial #: ❑ ❑ line test programmed ❑ Caldwell System ❑ Other Leak detector Primary piping testing at: ❑ ❑ mechanical Model: minutes ❑ electronic Serial #: ❑ line test V22Lammed Sump(s) UST(s) sor Testing for the above components are next due by: ❑ positive shutdown Model: o Cold start of monitoring panel ❑ fail safe Serial #: ❑ ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LIS letter 150-1) This UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ 111 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 21 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 4/30/12